Hindawi Publishing Corporation

Dermatology Research and Practice

Volume 2012, Article ID 198789, 18 pages
doi:10.1155/2012/198789

Review Article
The Infant Skin Barrier: Can We Preserve, Protect,
and Enhance the Barrier?

Lorena S. Telofski,1 A. Peter Morello III,2

M. Catherine Mack Correa,1 and Georgios N. Stamatas3
1 JOHNSON & JOHNSON Consumer Companies, Inc., 199 Grandview Road, Skillman, NJ 08558, USA
2 Evidence
Scientific Solutions, 123 South Broad Street, Suite 1670, Philadelphia, PA 19109, USA
3 JOHNSON & JOHNSON Santé Beauté France, 1 rue Camille Desmoulins, 92787 Issy-les-Moulineaux, France

Correspondence should be addressed to Lorena S. Telofski, ltelofs@its.jnj.com

Received 20 April 2012; Accepted 15 June 2012

Academic Editor: Alex Zvulunov

Copyright © 2012 Lorena S. Telofski et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.

Infant skin is different from adult in structure, function, and composition. Despite these differences, the skin barrier is competent
at birth in healthy, full-term neonates. The primary focus of this paper is on the developing skin barrier in healthy, full-term
neonates and infants. Additionally, a brief discussion of the properties of the skin barrier in premature neonates and infants with
abnormal skin conditions (i.e., atopic dermatitis and eczema) is included. As infant skin continues to mature through the first
years of life, it is important that skin care products (e.g., cleansers and emollients) are formulated appropriately. Ideally, products
that are used on infants should not interfere with skin surface pH or perturb the skin barrier. For cleansers, this can be achieved
by choosing the right type of surfactant, by blending surfactants, or by blending hydrophobically-modified polymers (HMPs)
with surfactants to increase product mildness. Similarly, choosing the right type of oil for emollients is important. Unlike some
vegetable oils, mineral oil is more stable and is not subject to oxidation and hydrolysis. Although emollients can improve the skin
barrier, more studies are needed to determine the potential long-term benefits of using emollients on healthy, full-term neonates
and infants.

1. Introduction
Skin barrier function resides primarily within the stratum
corneum (SC), the top layer of the epidermis. Although the
SC is only 7–35 μm thick [1, 2], it plays a vital role in forming
a protective barrier and helps to prevent percutaneous entry
of harmful pathogens into the body [3, 4]. In addition to
serving as a physical barrier, the SC has other important
functions, including engaging in thermoregulation, gas
exchange, and maintenance of proper hydration. The SC also
serves important functions in innate immunity [5] and its
slightly acidic pH [6] provides additional protection against
pathogens.
Maintenance of the skin barrier is essential for survival
[1]. This is especially true for neonates and infants because
their skin differs from mature adult skin in structure,
function, and composition [1, 2, 7] and is particularly
susceptible to infection [3]. During the late fetal period (20
weeks to birth), skin becomes functional and develops a
protective barrier [8]. Although full-term infants are born
with a competent skin barrier [9, 10], their skin is still
developing through the first year of life [2, 11]. During
the postnatal period, even the composition of commensal
bacteria residing on the skin surface differs from that of
adults and continues to evolve over the first year of life [12].
Given that skin continues to develop through the first
year of life, the use of appropriate, evidence-based skin care
practices is important. Maintaining skin barrier function
is critical to preventing organ dehydration [13]. The SC
water content is involved in maintaining SC structural
integrity and functionality [14]. It is generally accepted that
recommendations for infant skin care regimens should be
evidence-based [15]. Although several studies have evaluated
nonprescription emollient strategies to improve barrier
2 Dermatology Research and Practice
function [16, 17] or improve fluid and electrolyte balance
[18] in neonates, infants, or children with compromised skin,
limited information is available on skin care regimens that
enable maintenance or enhancement of skin barrier integrity
in normal neonatal or infant skin [19, 20].
Skin cleansing and emollient use are two simple strategies
that can help keep skin healthy. Proper skin cleansing helps
keep infant skin free of unwanted irritants, including saliva,
nasal secretions, urine, feces, fecal enzymes, dirt, and micro-
bial pathogens. Exposure to such factors for long periods,
especially in the diaper region, can lead to discomfort,
irritation, infection, and skin barrier breakdown. In many
cases, water alone is not sufficient to cleanse skin during
bathing [21]. Epidemiologic studies and anecdotal reports
have even suggested a possible link between household use
of hard water and atopic eczema in children [22, 23], though
a causal relationship has not been shown [24, 25].
In addition to using cleansers during bathing, emollient
use during or after bathing also may have benefits [16–
20, 26–29]. Emollients decrease transepidermal water loss
(TEWL) [16, 17, 26], improve skin condition [17, 26], and
may even lead to reduced mortality in extremely premature
infants [28]. In adults, 7 weeks of emollient use led to
improvement in skin barrier function [27].
In this paper, we discuss the unique structure, function,
and composition of infant skin, the importance of maintain-
ing skin barrier integrity, and best practices for maintaining
or improving infant epidermal barrier function, including
use of appropriately formulated cleansers and emollients. We
also discuss various neonatal and infant skin care guidelines
from around the world and some controversies surrounding
these guidelines. Finally, we will explore the idea that the
onset of emollient use from birth may play a role in
preserving and protecting the infant skin barrier later in life.
2. Infant Skin: Structure, Function,
and Composition
Infant skin is different from adult skin: it undergoes a
maturation process through at least the first year of life
[2, 7, 11]. Several groups have measured or compared the
epidermis of infants and adults [1, 2, 9, 30]. In one study,
the epidermis of full-term neonates at birth was found to
have 4.3 ± 0.7 cell layers that were vertically stacked from the
basal layer to the stratum granulosum (excluding the SC),
whereas the epidermis of preterm neonates at birth had only
2.9 ± 0.5 cell layers [9]. In their review of the literature,
Chiou and Blume-Peytavi [1] reported that SC thickness
ranged from 5.6 μm to 35.4 μm for infants and 15.2 μm to
35.4 μm for adults. Our group found that the suprapapillary
epidermis and the SC had respective thicknesses that were on
average 20% and 30% thinner in infants than in adults [2].
On the lower thigh area, infant SC was determined to be 7.3
± 1.1 μm, whereas adult SC on the same region was 10.5 ±
2.1 μm [2].
At birth, full-term neonates have competent barrier
function [10, 13] and an epidermis that appears to be
fully differentiated [9], but closer examination reveals subtle
structural and morphologic differences between infant and
adult skin [2]. These differences may lead to observable
functional differences between infant and adult skin [11].
Table 1 contains an overview of the major similarities and
differences between infant and adult skin.
The water-handling properties of infant skin are unique
and distinct from adult skin. Figure 1 shows a schematic of
infant and adult SC hydration and their respective water-
holding properties. Neonatal skin after birth is considerably
drier compared with that of adults [31, 32]. However, during
the first month of life, the difference in SC hydration between
infants and adults is reversed [32, 33], leading to increased
skin hydration in older infants (aged 3–24 months) relative
to adult skin [11, 34]. As skin becomes more hydrated, the
SC that is initially rough smoothens [32].
In addition to undergoing structural and functional
changes, the composition of the cutaneous microflora
evolves over the first year of life [12]. Although adult skin
is colonized mostly by the phyla Proteobacteria, Actinobac-
teria, and Firmicutes, the order of predominance changes in
infant skin to Firmicutes (predominantly Staphylococci), fol-
lowed by Actinobacteria, Proteobacteria, and Bacteroidetes
[12]. Although the implications of these findings are not yet
known, early microbial colonization is expected to influence
the development of immune function in skin. It also will
be important to characterize the further evolution of the
human skin microbiome during the first few years of life
to determine if commensal bacteria play a role in the
maintenance of skin barrier function beyond serving as
sentinels of innate immune defense [35].
3. The Skin Barrier Is Competent at Birth in
Healthy, Full-Term Neonates
After birth, skin barrier function is influenced by the shift
from an aqueous, warm environment in utero to a cooler,
arid, and more variable extrauterine world [11, 36]. Skin
development is contingent on gestational age. As gestation
increases, the thickness and the number of cell layers in
the epidermis increase [9]. Morphologic changes also occur,
including the formation of an increasingly undulated der-
moepidermal junction [9]. Histologically, a well-developed
epidermis emerges at 34 weeks of gestation [9], though
the period required for complete SC maturation has been
reported to vary between 30 and 37 weeks [10].
Although infant skin is different from adult skin [2, 11],
studies assessing the histologic and biophysical properties of
the SC have demonstrated that the skin barrier is competent
at birth in healthy, full-term neonates to prevent organ
dehydration [9, 10, 13]. The barrier properties of the skin
depend greatly on the thickness and integrity of the SC [8, 9].
As would be expected, preterm infants have a skin barrier
that is underdeveloped compared with full-term neonates
[9]. In one study [9], the epidermal thickness of full-term
neonates at birth was 43 ± 7 μm versus 31 ± 7 μm for preterm
infants (24–30 weeks of gestation).
In addition to SC thickness, other parameters can be used
to assess barrier function, including skin water-handling
Dermatology Research and Practice 3

Table 1: Infant and adult skin: similarities and differences.

Structural differences Infant skin Adult skin Reference
Epidermis
Corneocytes Smaller Larger [2]
Granular cells Smaller Larger [2]
Stratum corneum and epidermis Thinner Thicker [1, 2]
Microrelief lines More dense Less dense [2]
Depth of surface glyphics Similar to adult — [2]
Facultative pigmentation (melanin) Less More [142, 143]
Dermis
Dermal papillae (density, size, and morphology) More homogeneous Less homogeneous [2]
Distinct papillary-to-reticular dermis transition Absent Present [2]
Compositional differences
Epidermis
Natural moisturizing factor concentration Lower Higher [11]
pH Higher (newborn only) Lower [6, 32, 34]
Sebum Lower (7–12 month-old infant) Higher [144]
Stratum corneum water content Higher Lower [11]
Dermis
Collagen fiber density Lower Higher (young adult) [2, 145]
Functional differences
Rate of water absorption Higher Lower [11]
Rate of water desorption Higher Lower [11]
Skin barrier function Competent Competent [9, 10]
Transepidermal water loss Higher Lower [11]

(a) (b)

Figure 1: Infant and adult skin: stratum corneum (SC) hydration and water transport properties. The SC of infant skin (a) and adult skin
(b) is hydrated (small blue spheres) under normal conditions. Infant SC is more hydrated but also loses water at higher rates than adult SC
[11].
4 Dermatology Research and Practice
properties [11, 34]. Water barrier function and skin hydra-
tion status are interdependent factors, the former of which
is influenced largely by the organization and composition
of the intercellular lipid matrix [37], natural moisturizing
factor [38], and the permeation path length through the SC
[39]. Skin water content also influences skin barrier function
by regulating the activity of hydrolytic enzymes that are
involved in SC maturation and corneocyte desquamation
[40].
Researchers can assess the skin’s capacity to absorb
and retain water with sorption-desorption tests that use
electrical measurements (e.g., skin surface conductance or
capacitance) before and after topical application of water on
the skin surface [1, 41]. Water barrier function, which affects
rates of water absorption and desorption, is localized within
the SC [42] and has been shown to vary between infants
and adults [11, 31]. In addition, water content within the SC
can have a profound effect on skin surface morphology [43],
desquamation [44], and epidermal expression of keratins
and cornified envelope proteins [45].
Newborn skin has been reported to have lower skin
surface hydration and increased water loss compared with
skin from 1- to 6-month-old infants or adults [31]. Our
group also found that infant skin (3–12 months) on the
upper ventral arm and lower dorsal arm gained and lost
water at significantly faster rates than the same regions on
adult skin [11]. Skin surface hydration on the upper ventral
arm and lower dorsal arm was greater in infants than adults.
The distribution of water in the SC varied between infants
and adults based on water concentration profiles calculated
using confocal Raman microspectroscopy. Infants had more
water on the skin surface, more water within the SC, and
more water distributed throughout the first 26 μm below
the skin surface. Infant SC also had a steeper water gradient
compared with adult skin.
TEWL is a noninvasive method that can be used to
monitor changes in SC barrier function [46]; it also enables
dynamic measurement of water loss [11]. High basal TEWL
is suggestive of incomplete skin barrier function and is
indirectly proportional to the integrity of water barrier
function. This method has been used to confirm that
epidermal permeability barrier function is developed fully
at birth in full-term neonates [6, 10]. In older infants (3–
12 months) our group found that TEWL was significantly
higher compared with adult skin (P < .0005; 3–6 and 7–12
months old versus adult) [11].
Formation of an acidic SC is essential for epidermal
barrier maturation and repair processes [10]. Many factors
contribute to formation of the acid mantle, including sebum
secretion, sweat (lactic acid), amino acids and amino acid
derivatives (urocanic acid and pyrrolidone carboxylic acid),
and exocytosis of lamellar body contents at the stratum
granulosum/stratum compactum interface [47]. At birth,
full-term neonates have a skin surface pH that varies between
6.34 and 7.5 [6, 48]. Within the first 2 weeks of life, skin
surface pH falls to approximately 5 [3, 48], which is similar to
the skin surface pH that has been observed during adulthood
(pH range: 4.0 to 6.7) [6, 49]. Discrepancies in skin surface
pH between studies could be the result of differences in
participant age (infant versus child), gender mismatch, body
location (volar forearm versus buttock), or instrumentation.
It should be noted that adult skin surface pH also has
been shown to vary by a wide margin [49]. Taken together,
published data indicate that skin surface pH is close to
neutral at birth and becomes more acidic over the first few
days of life. Within a matter of weeks, skin surface pH is
similar to levels observed in adults. However, consensus has
not been reached on the duration of this transition period.
4. Maintenance of Skin Barrier Integrity
Is Essential to Overall Health and Wellness
Skin barrier function is essential for survival [1] and is
critical to preventing percutaneous entry of bacteria and
other pathogens into neonatal skin [50]. If the skin barrier
is disturbed, bacteria or bacterial factors will have access
to living epidermal keratinocytes and can induce defensive
immune responses [4]. Keratinocytes produce antimicrobial
peptides (AMPs), including the cathelicidin-derived peptide
LL-37 and human β-defensins 1-3 [4]. In the absence of
AMPs, pathogenic microorganisms can invade the surface of
skin, leading to infection or an imbalance of commensal flora
versus pathogenic bacteria. For example, patients suffering
from burns, chronic wounds, surgery, or injuries that are
associated with skin barrier dysfunction are more susceptible
to infections caused by Pseudomonas aeruginosa [4], yet this
opportunistic pathogen rarely causes infections on healthy
human skin [4].
5. Abnormal Infant Skin Conditions and
Barrier Integrity
5.1. Atopic Dermatitis (AD). During childhood, skin disor-
ders that are characterized by skin barrier dysfunction are
common. Compromised skin barrier integrity is thought to
be critical to the early onset and severity of AD, which is
often accompanied by dry, scaly skin. AD is an inflammatory
skin condition that occurs in 15–20% of children [51, 52].
Alterations in skin barrier properties that are observed in
AD include increased TEWL [53], changes in skin surface
pH [54], increased skin permeability [55], increased bacterial
colonization [56], alterations in AMP expression [57],
and compromised skin permeability barrier integrity [58].
Once the skin barrier is compromised, allergens, irritants,
and other unwanted agents can penetrate skin, leading to
aggravation of symptoms associated with AD.
There are several guidelines that discuss how caregivers
can manage and treat AD [59, 60]. Recommendations to
relieve AD include using warm water in lieu of hot water,
taking short baths (5–10 minutes), and using a liquid
cleanser with emollient that does not compromise skin
barrier integrity, followed by gentle dry patting with a soft
towel and immediate application of a skin emollient [29, 61].
The Royal College of Paediatrics and Child Health
(RCPCH) presented a tiered approach to the management
of mild, moderate, and severe atopic eczema [62]. In all
three cases, the RCPCH noted that initial treatment should
Dermatology Research and Practice
focus on repairing the skin barrier through the use of
emollients for moisturizing, washing, and bathing. Depend-
ing on severity, emollient use can be supplemented with
topical corticosteroids. In cases of moderate atopic eczema,
bandages and topical calcineurin inhibitors (second-line
treatment) can be used to supplement emollient use. During
severe atopic eczema, emollient use can be supplemented
with phototherapy and systemic therapy.
5.2. Irritant Diaper Dermatitis. Irritant diaper dermatitis is
a complex skin condition that is characterized by compro-
mised epidermal barrier function occurring on the buttocks,
perianal region, inner thighs, and abdomen. Skin occlusion,
friction, lipolytic and proteolytic activity of fecal enzymes,
increased skin surface pH, and prolonged exposure to urine
are all contributing factors to the onset of irritant diaper
dermatitis [63]. Greater than 50% of infants will have at least
one episode of irritant diaper dermatitis during the diaper-
wearing phase [64]. Clinical presentation of irritant diaper
dermatitis includes skin erythema [65], but severe cases may
lead to presentation of papules and edema [66].
Within the past 10 years, there have been several
reviews discussing the etiology and management of irritant
diaper dermatitis [67–71]. Although use of appropriately
formulated cleansers and emollients can help maintain the
epidermal skin barrier in the diaper region, good hygiene
and adequate protection are necessary to prevent skin barrier
breakdown, rash, and infection.
6. Cleansing Is Vital to Maintaining Good
Health and Hygiene
6.1. Infant Skin Care Guidelines, Recommendations, and
Review of the Literature. Keeping babies clean and good
skin hygiene are essential to overall health. Cleansing helps
keep skin free of unwanted substances, including irritants
(saliva, nasal secretions, urine, feces, and fecal enzymes),
dirt, and transient germs. Keeping hands clean, particularly
in the case of babies with their hand-to-mouth behaviors,
can help reduce or prevent oral transmission of microbial
contaminants. Caregivers should give special attention to
skin on the facial area, which may be irritated easily by milk,
food, and saliva. Skin folds and creases on the face also
should be kept clean.
Although the benefits of good hygiene are known,
neonatal skin cleansing and the use of cleansers, soaps, or
other topicals during the bathing process is controversial. For
most of the 20th century there were no formal guidelines
on neonatal skin cleansing. In 1974, the American Academy
of Pediatrics recommended that caregivers cleanse neonatal
skin after the infant’s temperature stabilizes [72]. In 1978,
Sweden and Great Britain proposed similar recommenda-
tions [73]. In 2007, the Second Edition of the Associa-
tion of Women’s Health, Obstetric, and Neonatal Nurses
(AWHONN) Neonatal Skin Care Evidence-Based Clinical
Practice Guideline recommended that caregivers select mild
cleansing bars or liquid cleansers that have a neutral pH
(5.5 to 7.0) that are preservative-free or contain preservatives
5
that have a demonstrated safety/tolerance profile [74].
In contrast, the National Institute for Clinical Excellence
(NICE) clinical guideline 37 on postnatal care states the
following [75]: “Parents should be advised that cleansing
agents should not be added to a baby’s bath water nor should
lotions or medicated wipes be used. The only cleansing agent
suggested, where it is needed, is a mild non-perfumed soap.”
Despite these recommendations, there is limited evidence to
support the NICE position on infant cleansing [29]. Water
is insufficient for removal of all oil-soluble skin surface
impurities [76, 77] and has poor pH-buffering action [78].
Depending on bathing frequency and quality of water used,
washing with water alone can have a drying effect on infant
skin [29], which may lead to impairment of infant skin
condition. Although soap is an effective skin cleanser, it can
disrupt skin surface pH, alter skin lipids, and cause dryness
and irritation [79–81], all of which may make soap less
preferable.
On 13 February 2007, a group of clinical experts
in pediatrics and dermatology formed the first European
Round Table meeting on “Best Practice for Infant Cleansing.”
The consensus panel recommended that caregivers use
liquid, pH-neutral, or mildly acidic cleansers over traditional
alkaline soaps on neonates and infants [29]. In addition, the
consensus panel made the following recommendations:
(i) Liquid cleansers are preferable to water alone.
(ii) Liquid cleansers cleanse and hydrate skin better than
water alone.
(iii) Liquid preparations, which often contain emollients,
are preferable to cleansing bars.
(iv) Liquid cleansers should contain adequate and appro-
priate preservatives.
(v) An “ideal cleanser” is one that does not cause
irritation, alterations to skin surface pH, or eye
stinging.
(vi) Skin care products should be selected on the basis of
evidence acquired in practical use conditions.
Although the consensus panel recommended using liq-
uid cleansers and believed that liquid cleansers have some
desirable properties, to our knowledge no peer-reviewed
publications have summarized the results from randomized
controlled trials comparing the tolerance or efficacy of liquid
or rinse-off cleansers to traditional soaps or syndet bars. In
an open-label, controlled, randomized study, Gfatter et al.
compared the effects of washing infant skin with a liquid
detergent (pH 5.5), compact detergent (pH 5.5), or alkaline
soap (pH 9.5) with a control group washing with water alone
after a single wash [79]. Their study was designed to assess
the effect of skin care regimens on pH, fat content, and skin
hydration. Although all cleansing regimens tested (including
the control) were shown to influence the parameters studied,
the soap bar had the largest influence on skin pH and fat
content, resulting in statistically higher pH (more alkaline)
and statistically greater loss of fat. The study by Gfatter et
al. concluded that the short-term effects from a single wash
can disturb the skin acid mantle and its protective function,
6 Dermatology Research and Practice
which suggests the need to determine the long-term effects
of cleansing products and other skin care regimens [81].
Given the lack of harmonization across infant skin
cleansing guidelines, bathing practices vary widely. Siegfried
and Shah surveyed skin care cleansing practices in 15
neonatal nurseries from 12 hospitals in Missouri, Iowa,
Illinois, and California [82]. Of these nurseries, four were
defined as “low risk” and 11 were defined as “high risk.” Head
nurses, nursery directors, or other healthcare professionals
were asked questions about bathing practices, cord care,
and general infant skin care. Bathing of full-term infants in
the low-risk nurseries occurred on the first day when the
infant was stable or when the infant’s core temperature was
98.6◦ F. There was little variation in the cleansing products
used during bathing. Nine of 15 nurseries used a mild baby
cleanser. One nursery used more than one brand, and no
information was given about the cleansing products used at
the other five nurseries.
Garcia Bartels et al. evaluated the effect of bathing with or
without a liquid cleanser on skin barrier function in healthy,
full-term neonates [19]. TEWL, SC hydration, skin surface
pH, and sebum were measured on the forehead, abdomen,
upper leg, and buttock on day 2, week 2, 4, and 8 of life. After
8 weeks of life, skin surface pH was significantly lower in
neonates who were bathed with a liquid cleanser versus those
who were bathed with water alone. Bathing with a liquid
cleanser did not lead to significant differences in median
TEWL values or SC hydration on any of the tested body sites
versus those who were bathed with water alone. Moreover,
use of a liquid cleanser did not lead to statistically significant
changes in sebum measurements. The use of a liquid cleanser
was well tolerated in healthy, full-term neonates during the
first 8 weeks of life. The study by Garcia Bartels et al. did not
include premature neonates or infants with abnormal skin
conditions and it is not known if similar observations would
be made in premature neonates or those with compromised
skin.
In a randomized, investigator-blinded clinical study,
Dizon et al. compared the effects of twice-daily washing with
water alone versus washing with water and a mild cleanser or
water with a comparator cleanser for 2 weeks in 180 healthy
infants [83]. After 2 weeks, cleansing with water alone led to
a significant increase in erythema from baseline. In contrast,
there was no change in skin erythema from baseline in the
group that was cleansed with water and mild cleanser.
6.2. Formulation Considerations. Many traditional soaps
contain detergents that are derived from saponification (e.g.,
the process of mixing a strongly alkaline solution with a fatty
substance such as vegetable oil or tallow, leading to soap
formation) [76]. Alkaline soaps can increase skin surface
pH beyond what is considered an ideal range [76, 79];
they can also dissolve fat-soluble and water-soluble barrier
components from the surface of skin [79]. Unlike traditional
soaps, many of which can be irritating, infant cleansers
should be mild to accommodate the maturing skin barrier.
Infant cleansers should also wash away dirt, sebum, saliva,
urine, fecal matter, and fecal enzymes with minimal effort
[66, 80, 81].
Although most cleansers and soaps are suitable for adult
bathing, cleansers for neonatal or infant skin should be
formulated specifically for that population and its special
needs. An ideal infant cleanser should contain at least
one “surface-active agent” (surfactant), a molecule with
both hydrophilic and oleophilic (lipophilic) properties that
reduces the interfacial tension between oil and water. Sur-
factants enable formation of oil-in-water, water-in-oil, and
more complex, multiphasic systems. By reducing interfacial
tension, cleansers help to emulsify oils and other skin surface
impurities into water [77], making their removal easier
without requiring excessive friction or mechanical force
during bathing.
Several classes of surfactants are used often in cleanser
formulations, including anionic surfactants such as sodium
lauryl sulfate (SLS) or sodium laureth sulfate (SLES),
nonionic surfactants (e.g., poloxamers), and amphoteric
surfactants (e.g., cocamidopropyl betaine). Foaming action
and mildness are influenced by the charge of a surfactant’s
hydrophilic head group and the formation of spherical
structures (micelles) that enable solubilization of oils and
lipids from the skin surface [21]. Although anionic and
amphoteric surfactants facilitate foam formation (a desirable
aesthetic property for shampoo), they are usually less mild
than nonionic surfactants such as polyethylene glycol (PEG)-
80 sorbitan laurate.
Surfactant selection represents a tradeoff between func-
tionality, aesthetics, and mildness. Due to their charge and
ability to form smaller micelles relative to other surfactants,
some anionic surfactants can be disruptive and irritating to
skin [21, 81]. For example, SLS is an effective emulsifying
and foaming agent, but in certain circumstances it may
cause irritation [81, 84]. In contrast, PEGylated nonionic
surfactants (e.g., PEG-80 sorbitan laurate or polyethylene
oxides) can lead to micelle stabilization, potentially increas-
ing cleanser mildness [21]. Cleansers containing sulfated
ethoxylated alcohols (e.g., SLES), surfactants that have large
head groups and have the ability to form larger micelles, may
be formulated to have improved mildness compared with
those containing SLS [84, 85]. In 20 healthy adult volunteers,
patch testing revealed that SLES was milder and caused
significantly less damage to the epidermal barrier compared
with SLS [84]. After 7 days, no significant irritation was
observed with SLES, even at the highest tested concentration
(2.0%). Regeneration after skin irritation occurred much
faster with SLES compared with similar concentrations of
SLS [84]. In 2010, the Cosmetic Ingredient Review (CIR)
panel concluded that SLES is safe as a cosmetic ingredient
when used appropriately in products formulated to be
nonirritating [86].
Mild moisturizing cleansers are expected to provide
cleansing benefits without negatively altering the hydration
and viscoelastic properties of skin [81]. Formulators can
combine surfactants to create milder cleansers [21], which
may be particularly ideal for individuals with AD [87].
For example, liquid body cleansers that contain a blend
of anionic and amphoteric surfactants can be milder than
Dermatology Research and Practice
a liquid cleanser that contains an equal proportion of
anionic surfactant alone. The blending of hydrophobically-
modified polymers (HMPs) with surfactants also may lead
to increased cleanser mildness [88]. HMPs can interact with
and associate with the hydrophobic tails of other surfactants,
leading to self-assembly and the formation of larger surfac-
tant/polymeric structures. The creation of micelles with a
larger hydrodynamic diameter has been shown to have lower
irritation potential and may ultimately allow for the creation
of milder surfactant systems and better tolerated cleansers
[88].
The properties of an ideal infant cleanser are summarized
in Table 2. Traditional cleansers are formulated to have a pH
that is similar to that of the skin surface. Liquid cleansers
should be nonirritating and should enable maintenance of
normal skin surface pH [29]. If the pH of a cleanser is
acidic but does not perturb skin surface pH, it may be
preferable to one that is pH neutral that causes a greater
shift in skin surface pH. Solutions that are not pH neutral
are not necessarily more irritating to skin. Moreover, it
could be argued based on the weight of the evidence that
alkaline cleansers would be least appropriate. Alkaline soap
can disrupt skin surface pH [79], decrease SC thickness
[89], decrease SC intracellular lipids [89], and lead to
dryness and irritation [80, 81]. Buffer solutions with varying
pH (4.0 to 10.5) were shown to be nonirritating to skin
irrespective of pH [90]. In addition, detergents buffered at
pH 3.5 or 7.0 caused similar levels of skin irritation [90].
Although cleansers can alter skin surface pH, temporary pH
fluctuations may be stabilized by the skin’s large buffering
capacity [90]. A cleanser’s effect on skin surface pH may
be more important than the pH of the formulation itself in
determining product mildness.
There are conflicting reports in the literature about
the effect of cleansers on cutaneous commensal bacteria.
Maintaining a skin surface pH between 4.0 and 4.5 facilitates
cutaneous commensal bacterial attachment to the surface of
skin [49]. Larson and Dinulos hypothesized that inappro-
priately formulated soaps could alter the delicate balance
between cutaneous commensal and pathogenic bacteria [3].
da Cunha and Procianoy investigated the effect of using
a pH-neutral soap during bathing on cutaneous bacterial
colonization in infants admitted to a neonatal intensive
care unit [91]. After 1 week, the use of a pH-neutral soap
did not have an effect on cutaneous bacterial colonization
compared with infants who were bathed with water alone.
Given the importance of cutaneous commensal bacteria to
innate immunity [92], the use of mild cleansers that do not
cause alterations in skin surface pH may be important for
normal skin maturation and innate immune function.
6.3. Noninvasive Approaches to Predict Skin Irritation Poten-
tial. Interleukin-1α (IL-1α) and prostaglandin E2 mediate
inflammation in skin via cytokine-dependent and arachi-
donic acid-dependent pathways, both of which play a role in
the development of erythema and edema. Proinflammatory
markers (including IL-1α) that are indicative of subclinical
inflammation (i.e., erythema) may be useful in predicting the
skin irritation potential of a skin cleansing product [93, 94].
7
Bernhofer et al. demonstrated that IL-1α can be a
useful predictor of skin mildness and irritation potential
[93]. Levels of subclinical irritation—even in the absence
of visible erythema—can be determined using a noninva-
sive epidermal tape-stripping technique and enzyme-linked
immunosorbent assay [95, 96]. IL-1 receptor antagonist (IL-
1ra), IL-1α, and the ratio between these two molecules
are useful for assessing skin reactivity [95] and measuring
skin inflammation [95, 97]. The IL-1ra/IL-1α ratio increases
during infancy, irritant diaper dermatitis, heat rash, and
erythema [96]. By extension, the IL-1ra/IL-1α ratio also may
help predict the irritation potential of skin cleansers [93].
It is anticipated that skin treated with a mild skin cleanser
would have a lower IL-1ra/IL-1α ratio compared with skin
treated with a more irritating cleanser, possibly leading
to a more normalized skin condition. Table 3 shows the
proinflammatory activity of several commercially available
cleansing products whose irritation potential was assessed by
measuring IL-1α release using in vitro skin tissue equivalents
(EpiDerm, MatTek Corporation, Ashland, MA, USA). A mild
baby cleanser and mild baby shampoo caused less IL-1α
release compared with a commercial sensitive skin syndet
bar. Moreover, MTT cell proliferation (cell viability) assay
data revealed that there was more cell cytotoxicity associated
with the sensitive skin syndet bar. Although these data are
from in vitro skin equivalents, the mild baby cleanser and
mild baby shampoo would be expected to cause minimal
release of IL-1α from infant skin, possibly leading to less skin
irritation. Other methods for assessing cleanser mildness
include measuring the percutaneous transit time, protein
solubilization, or collagen-swelling potential [98].
7. Emollients Can Improve Skin Barrier
Function in Healthy, Full-Term Neonates
Dry, scaly skin is common in neonates [31] but can occur at
any stage of development. Although many factors contribute
to skin surface hydration, the environment (i.e., dry, cold
weather or wind) can accelerate the loss of moisture from
the SC. Emollients have been used for centuries to protect
the integrity of the SC and to maintain skin barrier function
[99]. Appropriately formulated emollients can preserve,
protect, and enhance the infant skin barrier by supplying
the SC with water and lipids and by helping to inhibit water
loss. Emollients also supply lipids to epidermal keratinocytes,
where they can be transported through the cell membrane
and metabolized within the cell [100]. Keratinocytes can then
use lipids (including linoleic acid) as components to build a
functional epidermal barrier [101].
Several studies have shown that emollient use can
improve skin barrier function [16, 17] or improve fluid and
electrolyte balance [18] in preterm infants, but very few
studies have investigated the use of emollients on healthy,
full-term neonates [19, 20]. Garcia Bartels et al. investigated
the effect of applying topical emollients on healthy, full-term
neonates after bathing with or without liquid cleanser on
skin barrier function during the first 8 weeks of life [19].
After 8 weeks, median TEWL was significantly lower on the
8 Dermatology Research and Practice

Table 2: Ideal properties of appropriately formulated cleansers for neonates and infants.

Property Traditional cleanser Infant cleanser

Surfactant systems Amphoteric, anionic Amphoteric, nonionic, and ethoxylated anionic
Micelle diameter Smaller Larger
pH Slightly acidic to neutral pH pH should cause minimal changes to skin surface pH
Estimated IL-1ra/IL-1α ratio Larger Smaller
Preservative system Some claim preservative-free Product should be “microbiologically robust”
Lower concentration level; restrictions on specific fragrance
Fragrance (parfum/perfume) Higher concentration level components; fragranced product clinically evaluated for irritation
and sensitization potential
Product should be efficacious and should be demonstrated to be well
Other —
tolerated
IL-1α: interleukin-1α, IL-1ra: interleukin-1 receptor antagonist.

Table 3: Proinflammatory activity of commercially available cleansing products.

Cleanser IL-1α (pg/mL) MTT cell proliferation assay

Mild baby cleanser 100.5 ± 35.0 99.5%
Sensitive skin syndet bar 1150.1 ± 0.1 6.5%
Mean (± standard deviation) IL-1α (pg/mL) released from in vitro skin tissue equivalents (EpiDerm, MatTek Corporation, Ashland, MA, USA) after exposure
to various cleansing products. MTT cell proliferation (cell viability) assay data are also shown. The sensitive skin syndet bar had significantly more cell death
than the mild baby cleanser, IL-1α: interleukin-1α.

front, abdomen, and upper leg of neonates who received an
emollient after taking a bath with liquid cleanser (P < .001
for all regions versus infants who bathed with water alone
and did not receive an emollient after bathing). After 8 weeks,
median TEWL also was significantly lower on the forehead,
abdomen, upper leg, and buttock in neonates who received
an emollient after bathing with water alone (P < .001 for all
listed regions versus infants who bathed with water alone and
did not receive an emollient). Emollient use after bathing
with or without a liquid cleanser led to an improvement in
SC hydration on the forehead and abdomen (P < .001 versus
infants who bathed with water alone and did not receive an
emollient). Moreover, use of an emollient did not affect skin
surface pH or sebum production.
Many healthcare practitioners and caregivers understand
the utility of incorporating mild, appropriately formulated
cleansers into the bathing routine, yet far fewer caregivers
recognize the importance or benefits of emollient use for
application on healthy neonatal and infant skin. In a recent
study, 90% of the mothers surveyed believed that their
child’s skin was not dry, yet clinical evaluation revealed
that only 37% of these children had nondry skin, whereas
the remaining children exhibited clinical signs of low to
moderately dry skin [102].
7.1. Formulation Considerations. Similar to the case of
cleansing products, appropriate formulation of emollient
products need to take into account the particular nature
of infant skin properties [7, 11]. Some considerations that
may be important when selecting a skin care emollient
product are summarized in Table 4. Although this table is
not meant to be an exhaustive list, we have attempted to
provide practical considerations relating to preservative sys-
tems, fragrances, and the reasons behind other formulation
considerations.
It has been postulated that emollient products containing
a physiologic balance of epidermal lipids (3 : 1 : 1 : 1 molar
ratio of cholesterol/ceramide/palmitate/linoleate) are opti-
mal for barrier repair [103]. Furthermore, many compounds
(used alone or in combination with other molecules) have
been reported to have beneficial effects on skin barrier
function. However, due to the complex nature of emol-
lient formulations and differing individual needs, designing
emollients that are optimized for a particular individual and
tailoring the emollient for maximum efficacy are still active
areas of research [104].
Oils are used traditionally in some countries as emol-
lients during the bathing process [105–109], to treat
hypothermia in newborns, [110], or to remove impurities
from neonatal skin hours after birth [111]. Some derma-
tologists have recommended using bath oils for their ability
to leave a film on the skin surface or to reduce xerosis
[106–108]. One study [109] found that bath oils can be
beneficial to infants, yet another double-blind, randomized
study showed that some bath or shower oils can be irritating
to skin [112]. More recently, an analysis of systematic review
found that there was no benefit associated with using oils
to treat conditions like atopic eczema [113]. As noted
by Shams et al. [113], there is an absence of evidence
demonstrating a benefit of using bath emollients in addition
to directly applied emollients in the treatment of atopic
eczema. Furthermore, Tarr and Iheanacho [114] were not
able to find a randomized controlled trial that showed the
benefit of using bath emollients. Although the benefits of
Dermatology Research and Practice 9

Table 4: Practical considerations for emollient product selection.

Efficacy considerations
(i) Appropriate tests should testify to the efficacy of the product formulation
Safety considerations: overall
(i) The margin of safety for each ingredient at the concentration used in the formulation should be considered
(ii) Ingredients in a product can behave differently than in isolation; therefore, it is important to evaluate the full formulation for safety and
potential dermal effects, including irritation and sensitization
Safety considerations: fragrance
(i) The use of fragranced products for healthy neonates and infants should be supported by evidence for safety and tolerance
(ii) Fragrances should be compliant with the International Fragrance Association (IFRA), which is a body that helps to ensure the safety of
fragrance materials
Safety considerations: preservatives
(i) Products should be microbiologically robust
(ii) “Natural” does not always mean safer (e.g., some natural oils (eucalyptus, sage, and tea tree oils) can be toxic at certain levels)
(iii) Preservative ingredients can be natural or synthetic as long as their safety profile is documented; identical chemical structure means
identical safety profile
Safety considerations: labeling and packaging
(i) Directions for product use should communicate and educate parents on safe and appropriate use
(ii) Package design should help to minimize product contamination (e.g., loose top or seal could expose product to microbes)

using oils to improve the skin barrier remain equivocal, bath
oil use may have a soothing or calming effect on infants
when used during massage or bathing [115, 116]. Moreover,
the incorporation of emollients into the bathing routine
may provide emotional benefits such as reinforcement of the
parental or caregiver bond through touch [29].
While bath oils may not have an obvious benefit, some
emollient formulations contain essential fatty acids (e.g.,
linoleic acid) that can provide systemic benefits to neonates
[117]. Not all vegetable oils are appropriate for use on skin
[118]. Vegetable oils can vary in composition, for example,
in the ratio of linoleic to oleic acid. Some vegetable oils,
including certain olive, soybean, and mustard oils, can be
detrimental to the integrity of the skin barrier [119]. Some
unsaturated free fatty acids can act as permeation enhancers
[120], an effect that may cause contact dermatitis in adults
[121–124]. In addition, many vegetable oils are unstable
and degrade by hydrolysis and oxidation. Degradation can
increase the likelihood of microbial growth and spoilage,
especially in hot, humid environments. Cutaneous Propioni-
bacterium acnes and Propionibacterium granulosum secrete
lipases, enzymes that hydrolyze sebum triglycerides to free
fatty acids [125]. By extension, Propionibacterium acnes,
Propionibacterium granulosum, and possibly other cutaneous
bacteria may hydrolyze vegetable oils present in topicals into
free fatty acids, accelerating the degradation of vegetable oils
on the skin surface. Use of unstable emollients or those that
degrade quickly may lead to undesirable effects, especially on
infant skin that is undergoing SC maturation and expansion
of innate immune function.
Emollients that contain inert, stable ingredients such as
mineral oil are preferable for use on the maturing infant skin.
Mineral oil, a semiocclusive ingredient that penetrates the
upper layers of the SC [126], is immiscible with water. It is
noncomedogenic [127], has a long record of safe use [128],
and is unlikely to go rancid even in hot, humid climates.
Mineral oil helps to enhance the skin barrier as shown by
a reduction in TEWL following topical application of the
oil [126]. By reducing the amount of evaporated water, it
helps keep the SC more hydrated, leading to an improved
appearance on the skin surface. Other favorable physical
properties of mineral oil include a low viscosity and a low
specific gravity relative to water.
The semiocclusive mineral oil layer on the skin surface
helps to retain water by retarding water evaporation [126].
In an unpublished experiment, our group investigated the
effects of mineral oil on water retention in excised human
SC. Equal weights and sizes of human SC were dehydrated
at a constant temperature and humidity for 48 hours. After
dehydration, the weights of the human SC samples were
recorded. One set of samples (group 1) underwent full
hydration by placing the samples in a closed chamber (90%
humidity) for 48 hours. At the end of this period, the “wet”
sample weight was recorded. A second set of samples (group
2) was allowed to equilibrate to room temperature. Once
complete, sample weights in group 2 were recorded. The
weight of the hydrated samples was calculated by taking
the average percentage of the wet sample weight (group
1) minus the average percentage of the room equilibrated
sample weight (group 2). A third set of samples (group 3;
control) was maintained at dry weight until use. Mineral oil
was applied to the fully hydrated samples in group 1, while
two other moisturizing lotions were applied to the samples in
group 2. Mineral oil and test lotions were weight-adjusted to
ensure that equivalent weights of oil, lotion, and water were
applied to human SC (some of the lotions contained water,
10
whereas mineral oil contained none). Weight measurements
were taken immediately after product application on all
samples; weights also were recorded periodically until there
was no further decline in sample weight (i.e., complete
evaporation of SC water). In the absence of mineral oil,
SC moisture evaporated quickly, whereas samples with
mineral oil showed higher water retention. Figure 2 shows a
hypothetical model for how a semiocclusive layer of mineral
oil could improve the water barrier. In the left panel, no
mineral oil is present. In the right panel, water evaporation
from the surface of skin slows in the presence of mineral oil,
leading to reduced TEWL.
Another approach to enhance the skin barrier of infant
skin is to combine the emollient ingredients within the
liquid cleanser formulation [29]. More studies are needed to
determine specifically which types of emollient formulations
will be optimal for neonatal and infant skin.
8. Use of Emollients on Compromised Skin
8.1. Premature Infants. Gestational age is strongly linked to
epidermal barrier function. The skin barrier of premature
infants is injured easily and can serve as a portal of entry
for agents, causing serious bacterial infections [13, 129].
Several groups have investigated using vegetable seed oils
to improve skin barrier function in premature infants of
various ages [28, 100, 119, 130]. Although several studies
have shown that emollient use can decrease the frequency
of dermatitis or improve skin integrity in very premature
newborns [16, 17, 26, 131], there is controversy about the
use and effectiveness of emollients in high-risk neonates and
infants.
In 2004, Conner et al. [132] reviewed the effectiveness of
prophylactic application of topical ointments on nosocomial
sepsis rates and other complications in premature births. In
their meta-analysis, they included infants (n = 1304) with a
gestational age <37 weeks who received an emollient within
96 hours of birth. They found that prophylactic application
of topical ointments increased the risk of coagulase negative
staphylococcal infection (typical relative risk (RR) 1.31, 95%
confidence interval (CI) 1.02–1.70; typical risk difference
0.04, 95% CI 0.00–0.08), any bacterial infection (typical RR
1.19, 95% CI 0.97–1.46; typical risk difference 0.04, 95% CI
0.01–0.08) and nosocomial infection (typical RR 1.20, 95%
CI 1.00–1.43; typical risk difference 0.05, 95% CI 0.00–0.09).
One limitation of this paper was that it included only four
studies [16, 17, 26, 131], which reflects the limited number
of studies that had been published at that time. It remains
to be seen if the conclusions of the meta-analysis would be
applicable for other topicals or emollients.
In the studies that observed higher rates of infection
[16, 26, 131], several possible explanations have been
proffered as to the cause. Conner et al. [132] speculate
that contamination may have occurred during application
of the preservative-free petrolatum ointment or that its
use may lead to conditions suitable to proliferation of
bacterial organisms. Visscher [133] posits that skin occlusion
on extremely low birth weight neonates may have delayed
barrier maturation.
Dermatology Research and Practice
It might be further reasonably speculated that increased
rates of nosocomial infections could have been due to use
of a preservative-free petrolatum-based ointment that was
opened and exposed to pathogenic organisms. Although it
is unlikely that a preservative-free petrolatum-based product
manufactured using good manufacturing practices would
become contaminated, inadvertent addition of excessive
moisture from a damp environment (i.e., bathroom) could
lead to product contamination. Similar to petrolatum,
mineral oil is anhydrous, yet there is evidence that it
can become contaminated by improper handling [134].
Given these considerations, formulators should select an
effective preservative system, even when formulating low
water activity emollients.
Several studies have found very high concentrations
(>104 colony-forming units (CFU)/g) of microbial con-
taminants in consumer products that are poorly preserved
or preservative-free [135, 136]. Use of a poorly preserved,
contaminated emollient led to an outbreak of P. aeruginosa
in a neonatal intensive care unit [137]. Furthermore, use
of preservative-free white petrolatum has been linked to
systemic candidiasis [138].
Since publication of the meta-analysis in 2004 [132],
other studies have also investigated emollient use in prema-
ture infants or neonates. In a randomized controlled trial,
Darmstadt et al. evaluated the efficacy of a petrolatum-based
emollient and a sunflower seed oil with high-linoleate con-
tent on neonatal mortality rates among hospitalized preterm
infants (≤33 weeks gestation) at a large tertiary hospital
in Bangladesh [28]. Massaging high-risk infants with the
petrolatum-based emollient or the high-linoleate sunflower
seed oil led to a reduction in nosocomial bloodstream
infections (reduction rates for the respective treatments were
71% (95% CI: 17%–82%) and 41% (95% CI: 4%–63%)
relative to no treatment). Moreover, massage with either
product led to a significant decrease in neonatal mortality
(32% and 26% for the petrolatum-based emollient and
the high-linoleate sunflower seed oil, resp.) relative to the
standard of care for premature neonates (no treatment). In
contrast, use of the same petrolatum-based emollient on
extremely premature infants (birth weight 501 to 1000 g)
in the United States (and other countries) did not have an
effect on neonatal mortality [131]. Darmstadt et al. [28]
proposed that differences in trial design, study population,
treatment (i.e., access to life-saving interventions), and
environmental factors could help explain the differences in
neonatal mortality rates observed between the two studies
[28, 131].
LeFevre et al. [139] used a Monte Carlo simulation on
the data generated by Darmstadt et al. [28] and found that
use of the petrolatum-based emollient or sunflower seed oil
with high-linoleate content was a cost-effective strategy to
improve clinical outcomes. Relative to untreated premature
infants, the petrolatum-based emollient and sunflower seed
oil had respective costs of US$162 and US$61 per death
averted and respective costs of US$5.74 and US$2.15 per year
of life lost averted [139]. Although both products were cost-
effective strategies to reduce neonatal mortality in a hospital
setting, it is not known whether a reduction in mortality
Dermatology Research and Practice
(a)
Figure 2: Stratum corneum (SC) moisture retention following application of mineral oil emollient. In (a), transepidermal water loss (TEWL)
from the SC is shown under ambient temperature, humidity, and pressure. In (b), TEWL is reduced following emollient application. Oils in
the emollient create a semiocclusive layer. The reduction in water evaporation leads to greater water retention in the SC.
also would be observed in a low-resource community setting
outside the hospital, which is more typical of a normal
birthing environment in Bangladesh and other developing
countries [140].
Brandon et al. compared the effects of a composition
containing water, polymers, and odorless, nonalcoholic
evaporating agents or a petrolatum-based emollient on
skin barrier integrity over the first two weeks of life in
premature (<33 weeks gestation) infants [141]. A nine-point
neonatal skin condition score (NSCS) was used to assess
skin dryness, erythema, and skin breakdown. TEWL declined
significantly over time; there were no differences in TEWL
between treatment groups. The neonatal skin condition
scores for infants receiving the petrolatum-based emollient
were statistically better than those for infants receiving the
aqueous polymeric composition, yet both scores were within
normal range. Few infants in either treatment group had skin
breakdown.
Although many studies have investigated the use of
emollients in children or adults with eczema or AD, very
few studies have investigated the use of emollients in healthy,
premature, or full-term neonates. A summary of studies that
have investigated the use of emollients in healthy, preterm or
full-term neonates (0–4 weeks old) or infants (1–6 months
old) is shown in Table 5.
9. Emollient Use May Lead to Long-Term
Improvement in Skin Condition
To our knowledge, there are no randomized controlled trials
that have investigated the long-term use of emollients on
skin barrier function or overall skin condition. Nevertheless,
11
(b)
prophylactic use of emollients that are appropriately formu-
lated for use after birth may produce measurable benefits
later in life. To test this hypothesis, some members of our
team conducted a 6-week study on 51 infants (aged 3 to
12 months) that consisted of giving the infant participants
twice-daily baths with a mild baby cleanser, followed by
twice-daily application of one of three marketed lotions
(unpublished data). Infants were randomized to receive
one of three oil-in-water emollient formulations, each of
which contained different types of surfactants and other
ingredients. Skin barrier function was assessed indirectly by
measuring TEWL and SC hydration (skin conductance) on
the upper volar arm and lower dorsal arm. The effect of
each lotion varied among the three groups. Results indicated
that skin barrier function and SC hydration improved with
daily use of only one of the emollients over a period of six
weeks. These results suggest that emollient efficacy is related
to the specific chemistry and ingredients of the formulation.
Although no studies have investigated the long-term use
of emollients on infants, long-term emollient use could
improve the epidermal skin barrier and improve overall skin
condition relative to untreated skin.
10. Summary
Although the need for and benefits of good skin hygiene
are clear, recommendations for best cleansing and bathing
practices remain debated during infancy and early child-
hood. As infant skin continues to change throughout the
first years of life, its dynamic properties need to be addressed
with appropriate skin care routines. Use of mild surfactant
systems in cleansers can enable maintenance of skin barrier
integrity; these cleansers may also be minimally disruptive to
 12

Table 5: Emollient therapy in healthy, full-term, or premature neonates (0–4 weeks old) or infants (1–6 months old) on skin barrier function: literature review† .

Healthy, full-term infants

Endpoints/
Study Cohort Treatment Study duration Primary outcome(s)
measurements
Wash with emollient
Body wash; body wash with improved skin condition;
64 healthy, full-term neonates TEWL, SC hydration, skin
emollient use after bathing; water in some cases, lower TEWL
Garcia Bartels et al. [19] (gestation ≥37 weeks aged ≤48 8 weeks surface pH, sebum, NSCS, and
alone, followed by emollient after and higher SC hydration
hours) bacterial colonization
bathing were observed; no adverse
events
Reduced TEWL in both
44 healthy, full-term infants Lotion was applied after a
Garcia Bartels et al. TEWL, SC hydration, skin groups; site-specific
(≥37 weeks gestation) aged 3–6 swimming lesson once weekly or 5 weeks
[146] surface pH, and sebum differences in the treatment
months old no treatment
group were observed
Emollient consisting of
10 healthy, full-term neonates
ceramides, cholesterol, and free
(0–4 weeks old; gestation ≥36 TEWL, SC hydration, skin Emollient use reduced
Lowe et al. [147] fatty acids at a 3 : 1 : 1 ratio and 6 weeks
weeks) with a family history of surface pH, and sebum TEWL
2% petrolatum (applied once
allergic disease
daily)
Skin barrier measurements
22 full-term infants (≥37 weeks
remained within normal
gestation) considered to be at Oil-in-water, petrolatum-based
Simpson et al. [20] Up to 2 years TEWL and skin capacitance range; only three
high risk for developing atopic emollient cream
participants developed
dermatitis
atopic dermatitis
Premature Infants
The petrolatum-based
emollient led to a
Petrolatum-based emollient significant reduction in the
Fluids, electrolytes, bilirubin,
Beeram et al. [18] 54 infants (≤27 weeks gestation) applied every 6 hours or no 2 weeks need for fluids; it also led to
and sepsis
treatment better urine output, more
stable electrolytes, and
lower bilirubin values
Polymer, liquid-based film
Both treatments were well
(applied twice) or Total fluid intake, TEWL, and
Brandon et al. [141] 69 infants (<33 weeks gestation) 2 weeks tolerated; both led to a
petrolatum-based emollient neonatal skin condition
decrease in TEWL
(twice-daily application)
Dermatology Research and Practice
 Table 5: Continued.
Healthy, full-term infants
Endpoints/
Study Cohort Treatment Study duration Primary outcome(s)
measurements
Sunflower seed oil and
petrolatum-based
Sunflower seed oil or
emollient reduced
petrolatum-based emollient (3
Dermatology Research and Practice

Darmstadt et al. 497 premature infants (≤72 Survival rate and rate of mortality by 25–30%;
times daily for 14 days, then ≥14 days
[28, 100, 148] hours old; gestation ≤33 weeks) nosocomial infection sunflower seed oil reduced
twice daily until hospital
nosocomial infection rates
discharge) or no treatment
by a statistically significant
margin
Emollient decreased
dermatitis of the hands
Twice-daily application of a
34 neonates (29–36 weeks TEWL, NSCS, and quantitative (days 2–11), feet (days
Lane and Drost [16] water-in-oil emollient; no 16 days
gestation) microbiology 2–16), and abdomen (days
treatment
7–11); no changes in
microbial flora
Emollient use led to
statistically significant
decrease in TEWL;
significant improvement in
Temperature, TEWL, fluid
infant skin condition on
Petrolatum-based emollient intake, weight analysis, skin
60 neonates (<33 weeks days 7 and 14; less
Nopper et al. [17] (applied twice daily); no 2 weeks condition, microbiology, and
gestation) colonization of the axilla
treatment blood/urine analysis for
on days 2, 3, 4, and 14;
cerebrospinal fluid cultures
statistically significant
reduction of positive
findings in blood and
cerebrospinal fluid
TEWL: transepidermal water loss, SC: stratum corneum, NSCS: neonatal skin condition score.
† Studies published between 1 January 1960 and 1 June 2012 were identified by searching peer-reviewed literature indexed in PubMed. The titles and abstracts of indexed publications listed in PubMed were searched

using the following words: “newborn OR neonat∗ OR infant∗ ” (group 1), “emollient OR lotion OR cream OR topical” (group 2), and “skin” (group 3). These three groupings were connected using the Boolean
operators “AND”. The titles and abstracts were also searched using the word “vitro” and the Boolean operator “NOT”. Finally, only the titles of PubMed-indexed publications were searched using a fifth group of
words and were connected to the search string using the Boolean operator “NOT”: “injury OR wound OR burn OR damage OR eczema OR dermatitis OR psoriasis OR disease∗ OR pain OR hemangioma∗ OR
syndrome OR sepsis OR antisepsis.” Review articles, publications that were printed in a language other than English were also excluded. Although our search generated 220 publications, only 9 (summarized in
Table 5) met the search criteria described above.
13
14
skin surface pH and have minimal potential to stimulate the
production of IL-1α and other proinflammatory molecules.
Emollients can provide benefits to premature infants or
infants with compromised skin barrier function. Few studies
to date have demonstrated the benefits of emollient use on
healthy, full-term infants. In addition to providing short-
term benefits such as maintaining or improving skin barrier
function, it is hypothesized that long-term use of emollients
may produce lasting benefits to skin barrier function and
overall skin condition. In the future, harmonization of
neonatal and infant skin care guidelines—including use of
properly formulated cleansers and emollients—is warranted.
Acknowledgment
The authors thank Russel M. Walters, Ph.D. for providing
technical expertise on cleansers and surfactants and for his
assistance with the IL-1α and MTT cell proliferation assay
data.
References
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